Inpatient/Residential Treatment for Individuals with a Gambling Disorder Overcoming Treatment Ambivalence 1 Sheryl Anderson
2 Learning Objectives Recognize when it is clinically appropriate to refer to an inpatient/residential gambling disorder treatment provider. Explore the challenges of working with a client who is ambivalent to inpatient/residential treatment. Explore strategies of motivational interviewing and readiness for change. Understanding admission process Overview of inpatient/residential treatment Continuum of care.
3 Identifiers Cues for Considering Residential Treatment Behavioral Signs Stops doing things previously enjoyed Misses family events Changes patterns of sleep, eating or sexual activity Ignores self-care, work, school or family tasks Have conflicts over money with other people Uses alcohol or other drugs more often Often late for work or school Organizes staff pools
4 Identifiers Cues for Considering Residential Treatment Behavioral Signs Leaves children alone, seems less concerned about who looks after them; neglects their basic care Thinks and talks about gambling all the time Is less willing to spend money on things other than gambling Cheats or steals to get the money to gamble or pay debts Has legal problems related to gambling Is gone for long, unexplained periods of time Neglects personal responsibilities
5 Identifiers Cues for Considering Residential Treatment Emotional Signs Withdraws from family and friends Seems far away, anxious or has difficulty paying attention Have mood swings and sudden outbursts of anger
6 Residential Treatment Screens South Oaks Gambling Screen (SOGS) Scores 0= No problem 1-4 = Some problems 5+ = Probable gambling disorder DSM-5 Score of 4 or more
7 Determining Appropriate Level of Care Risk of Harm Functional Status Medical, Addictive and Psychiatric Co-Morbidity Recovery Environment Treatment and Recovery History Engagement
8 Addressing Treatment Ambivalence There are many reasons why people with gambling problems don t get help. Research reveals that many people are unaware that specialized problem gambling services are available; others may refuse help because they are ambivalent about giving up gambling; have fear of being stigmatized or may be unaware that their gambling is connected to problems in their lives.
9 Patient Responses (what kept me from entering treatment) Continued hope of a big win, as long as I still have money there s a chance I can fix it by gambling Shame Pride Fear Obligations: family/ work/ pets Denial: it s not that bad, I ll just stop Did not want to quit
10 Contributing Factors to Treatment Ambivalence Lacks healthy coping skills Co-occurring mental health disorder(s) Co-occurring substance use disorder(s) Unresolved grief and loss, prolonged or complicated grief Anger and resentments History of trauma/abuse
11 Percentage of Gamblers With Co-Occurring Substance Use Disorders Alcohol use disorders: 73.2% Drug use disorders: 38.1% Mood Disorders Mood disorder: 49.6% Major depressive disorder: 37% Bipolar disorder: 22.8% Anxiety Disorders Anxiety disorders including generalized anxiety, panic disorder, social phobia and post-traumatic stress: 41.3% Personality Disorders Personality disorders including borderline, narcissistic, antisocial and histrionic: 60.8%
12 Cognitive Distortions; Contribute to Ambivalence Systems Overcome the house advantage by learning system Selective Recall Remember wins, forget losses Personification of a Gambling Device Human characteristics to gambling process machine is punishing them Near Miss Beliefs Mental reduction in losing experiences by thoughts of almost won
13 Cognitive Distortions Chasing Losses Money can be won back by further gambling Personalization Belief in personal control over external uncontrollable events Emotional Reasoning Emotions reflect reality I feel it, therefore it must be true.
14 Addressing Treatment Ambivalence Helpful strategies: Making calls from office to set up appointments, ask questions Meeting with family members separately/ family members are sometimes more willing to discuss the problems gambling has created more than the person with a gambling disorder Use of additional tools
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16 Stages of Change Precontemplation: Not yet acknowledging that there is a problem behavior that needs to be changed. Contemplation: Acknowledging that there is a problem but not yet ready or sure of wanting to make a change. Preparation/Determination: Getting ready to change. Action/Willpower: Changing behavior. Maintenance: Maintaining the behavior change. Relapse: Returning to older behaviors and abandoning the new changes.
17 Motivational Interviewing Motivating Client Change Express empathy Help client see consequences of gambling Avoid arguments Roll with resistance Support self-efficacy
18 Readiness to Change Tell me about your gambling history and what has led up to seeking treatment? If your gambling were to continue, what s your biggest fear? What concerns other people about your gambling? How has gambling kept you from reaching your goals/dreams? How has your gambling impacted your values/beliefs? How ready, willing and able are you to seek treatment for your gambling disorder (1-5 scale)? What are potential challenges to remaining abstinent from gambling? What would assist you in remaining abstinent?
19 Admission to Vanguard If client is ambivalent about residential treatment, consider a conference call with client, Vanguard, and initial provider When you have verbal commitment from client, call or e-mail (state specific) Contact Admissions at Vanguard: 1-800-862-1453
20 Funding Options Currently, Vanguard offers out-of-state treatment scholarships for $2,500. If the client does not complete treatment, they are required to pay Vanguard the $2,500. Specific state contracts
21 Project Turnabout s Vanguard Center for Compulsive Gambling Located in Granite Falls, MN 20-bed inpatient/residential treatment program Serves both men and women Exclusive treatment program for gambling disorder Able to treat chemical dependency in separate programs Multidisciplinary, 12-step, abstinence based treatment philosophy
Regional Treatment Center Four campuses in Minnesota Inpatient/Residential With on-site licensed detox Outpatient Treatment Continuing Care Programs OUR MISSION To operate services designed to help alcohol and drug dependent people, compulsive gamblers and perpetrators of domestic abuse or community violence.
Vanguard Center for Compulsive Gambling Residential Rooms 23
Vanguard Center for Compulsive Gambling Campus Amenities 24
25 Treatment Model Education Lecture series On-demand video series Therapy Education Therapy Individualized treatment plan Patient-to-counselor ratio less than 7:1 Fellowship Peer-to-peer Outside support groups Fellowship Recovery
Structure of Vanguard Program Individual and group therapy Education Family program Spiritual and fitness Structured activities Personal accountability
27 Family Involvement in Treatment Bi-weekly therapeutic and educational group sessions Open lines of communication Discuss on-going recovery Initiate the healing process For long distance families tools such as phone conferencing and Skype are available. No additional cost for family program
28 Pre-Admission Assessment Facility medical staff retrieves collateral information from: Patient and relatives/loved ones Primary physicians Mental health professionals Pharmacists Other medical professionals
29 Holistic Multidisciplinary Assessment Upon intake, each Vanguard patient receives a holistic assessment from a multi-disciplinary team that includes mental health, addiction, medical, and health & fitness professionals. This assessment is used to develop their individualized treatment plan. Dimensions Intoxication/Withdrawal Biomedical Assessment Emotional, Behavioral, Cognitive Readiness for Change Relapse, Continued Use Potential Recovery Environment
30 Strengths-Based Assessment Considers patient strengths, values and beliefs, goals, abilities, personal and environmental assets, and cultural/personal treatment preferences.
31 Biomedical Assessment Done by medical staff Detoxification needs Quick drug screen Medical history Gambling history Substance use history/chemicals of choice Release of medical records Intake physical Medication recommendations
32 Psychological Assessment 1. Emotional, behavioral and cognitive evaluation within first 24 hours of treatment 2. Substance use status and history 3. DSM-5 Multiaxial Diagnosis 4. Assessment of suicidality 5. Beck Depression Inventory 6. Quality of Life index 7. MMPI II 8. Off-campus medical/mental health evaluations and services
33 Clinical Interventions Rational Provide patient with a safe treatment "holding environment" that includes nurturing, trusting relationships. Method 12-Step facilitation Patient/counselor therapeutic alliance established in individual counseling sessions Supportive Peer/12-Step fellowship Group-based therapy Structured daily activities Clear guidelines and expectations Relationship skills development Group skills development
34 Clinical Interventions Rational Help patient acquire new information and experiences through education and treatment programming. Method Educational lectures/presentations, videos and books on addiction and co-occurring disorders Daily 12-Step meetings and groups Daily fitness and recreation activities Discussion on neurobiology of addiction, depression and anxiety Financial management counseling Relapse prevention Daily instruction and practice of coping strategies
35 Primary Coping Strategies Clinical Interventions Method 4-7-8 Breath Mindful Breathing Emotional Freedom Technique (Tapping) Mindfulness/Acceptance Meditation & Prayer Relaxation Guided Imagery Journaling Dealing with Urges and Triggers Tolerating Strong Emotions
36 Clinical Interventions Rational Foster patient's movement from dissociation and denial to thought and emotional awareness and expression. Method Daily feelings journaling 12-Step patient writing assignments and presentations Patient gambling history presentations Family education and therapy Therapeutic process comments Motivational Interviewing and Enhancement Solution-focused writing assignments (Miracle Question) Cognitive Restructuring
37 Clinical Interventions Rational Provide patient with opportunities to experience and tolerate strong emotional states and "safe emergencies," followed by times of processing, reflection, and ascribing new meaning. Method Empathic, non-judgmental, helping counselor stance 12-Step writing assignments and patient presentations Externalizing the problem Exercises in tolerating strong emotions Mindfulness/Acceptance meditations Urge Surfing and craving management Cognitive Restructuring Grief Facilitation Tapping (EFT) DBT
38 Quality of Live Inventory The Quality of Life Inventory s is used to: Screen for mental health and physical problems Measure patient progress People s life satisfaction is based on how well their needs, goals and wishes are being met in important areas of life
Percentile 39 Quality of Life Inventory Average Percentile Scores for Vanguard Patients (FY 12-13) 60 50 40 30 20 Before After 10 0 June 12' July 12' Aug 12' Sept 12' Oct 12' Nov 12' Dec 12' Jan 13' Feb 13' Mar 13' Apr 13' May 13' June 13' YEAR 2012 YEAR 2013 *Percentile scores are from 1 to 99 Scores for Percentiles: Very Low= 1 to 10 Low= 11 to 20 Average= 21 to 80 High= 81 to 99
Dissatisfaction Satisfaction 40 Self Esteem Scores Average Percentile Scores for Vanguard Patients (FY 12-13) 5 4 3 2 1 0-1 1 2 3 4 5 6 7 8 9 10 11 12 13 Before After -2-3 -4 *Chart is on a -6 to 6 scale for scoring
41 Quality Measures Discharge with staff approval Average rating of 87% Patient indicated overall program satisfaction FY 2012-2013: 95%
42 Continuing Quality Care After Inpatient/Residential Treatment Clinical recommendations include: 2-3 GA meetings per week Find a GA sponsor and have daily contact for 6 months Participate with Vanguard Alumni Recovery Network Continued outpatient gambling counseling
43 Collaboration Referral process Interaction with patient while in treatment Discharge planning
44 Thank you & Questions For additional questions or concerns please contact Vanguard Center for Compulsive Gambling Sheryl Anderson 1-800-862-1453 or sanderson@projectturnabout.org